Continuity of Care (90-day transition period)
Customize your policy alerts
Sign up for longevityhealthplanofcolorado Policy UM.041 alerts
Get alerted when Policy UM.041 changes without checking for updates manually.
Monitor payer policy activity
This policy governs continuity of care considerations for members newly enrolled in Longevity Health Plan of Colorado, defining a 90-day transition period and how prior authorization reviews are handled during that time.
No material clinical or coverage changes in this revision.
Continuity of Care — Coverage Criteria
Continuation of pre-enrollment treatment
Covered when ALL of the following are met for members in first 90 days of enrollment:
supported by chunk 5
supported by chunk 6
supported by chunk 7
If the member begins a new plan of care or a new treatment plan that was initiated after their enrollment date but within the 90-day transition window, standard prior authorization and utilization management requirements apply. Any prior authorization request received during the first 90 days will be reviewed to determine whether the requested service represents a treatment plan that began prior to enrollment or a new plan of care initiated after enrollment. If the plan is determined to be new, normal prior authorization criteria and UM policies remain in force and may result in denial if the request does not meet standard coverage requirements.
Provider Requirements and Prior Authorization
Prior authorization for continuing pre-enrollment treatment during 90-day transition
For members in their first 90 days of enrollment, prior authorization requests for continuation of a treatment plan initiated prior to enrollment will be approved without additional review when the request documents diagnosis, that the service is part of an existing plan of care, and that the service is Medicare-allowable; if the plan is new, normal prior authorization requirements apply.
- Review will be limited to (1) presence of an appropriate diagnosis/medical condition, (2) evidence that the service is part of an existing plan of care initiated prior to enrollment, and (3) confirmation that the service is a Medicare-allowable service.
- If review determines the treatment began prior to enrollment, authorization will be approved without additional UM review.
Step therapy and UM policies apply to new treatment plans within 90 days
If a treatment is new during the 90-day window (i.e., the plan of care was initiated after the member's enrollment date), applicable step therapy and other utilization management policies remain in force and will be applied under standard review.
- Determine whether the plan of care was initiated after the enrollment/effective date; if new, apply step therapy and UM requirements.
- Continuation exception does not apply to new treatment plans started within the 90-day period.
Documentation required for continuity approvals during 90-day transition
Prior authorization reviews within the first 90 days must include documentation of an appropriate diagnosis/medical condition, evidence that the service is part of an existing plan of care initiated prior to enrollment, and confirmation that the service is a Medicare-allowable service.
- Document the diagnosis or medical condition supporting the service.
- Provide evidence the service is part of an existing plan of care that began prior to the enrollment/effective date.
- Confirm the service is Medicare-allowable.
New treatment plans within 90 days are subject to standard UM review (denial risk)
If review determines the treatment plan is new (initiated after enrollment), traditional utilization management review and prior authorization requirements apply and may result in denial if the request does not meet standard criteria.
- Determine and document the treatment start date relative to the enrollment/effective date to establish whether the plan is new.
- Be aware that new plans started within 90 days are subject to full UM review and standard approval/denial criteria.
Policy Background
Continuity of care policies prevent disruption when members change health plans by allowing pre-existing treatment plans to continue during a defined transition period. Longevity Health Plan of Colorado provides a 90-day transition period during which services that are part of an existing plan of care initiated prior to the member's enrollment may be continued with streamlined review.
During this 90-day window, prior authorization requests that document an appropriate diagnosis/medical condition, demonstrate the service is part of an existing plan of care initiated prior to enrollment, and confirm the service is a Medicare-allowable service will be approved without additional review. Requests received in the first 90 days will be evaluated to determine whether they represent continuation of pre-enrollment treatment (eligible for streamlined approval) or a new treatment plan (subject to standard UM and PA requirements).
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.